NCLEX 3000 Maternal-Intrapartum
A client in active labor has severe second-degree burns on her buttocks. When questioned about the burns, the client replies, "I was trying to use that hot water thing to help my hemorrhoids." What should the nurse say in response to this client?
"Does your doctor know about the burns?"
A client in the early stages of labor asks the nurse whether it's really necessary for her to purchase a car seat, noting that they're very expensive. Which response by the nurse is best?
"The only way to safely transport your baby in a car is to have him restrained securely in a car seat."
(Select all that apply) A nurse is assigned to assist with the admission of a client who is in labor. Which of the following actions are appropriate?
(1) Asking about the estimated date of delivery (EDD), (3) Taking maternal and fetal vital signs, (6) Asking about the amount of time between contractions
(SELECT ALL THAT APPLY) The nurse is assisting in the delivery room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate delivery. Which interventions should the nurse perform when caring for the client after this procedure?
(1) Check the episiotomy repair site., (2) Apply ice to the perineum, (4) Administer pain medication, as prescribed., (5) Explain perineal care to the client when she is able to focus on the instructions.
(SELECT ALL THAT APPLY) The nurse is assisting in monitoring a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should be alert to which of the following maternal adverse reactions?
(1) Hypertension, (4) Fluid Overload, (5) Uterine Tetany
(SELECT ALL THAT APPLY) Which conditions are contraindications to epidural blocks?
(1) Infection at the injection site, (2) Allergy to the anesthetic drug, (4) Anticoagulant therapy, (5) Bleeding disorder
(SELECT ALL THAT APPLY) A client receives an epidural block for pain relief during labor. Which interventions by the nurse are important when caring for a client with an epidural block?
(1) Make sure oxygen is available., (3) Monitor vital signs frequently., (5) Monitor fetal heart rate and contractions closely.
(SELECT ALL THAT APPLY) A primigravida experiences spontaneous rupture of the membranes. What should the nurse do?
(1) Perform a nitrazine test to confirm that the membranes are ruptured, (2) Monitor fetal heart rate and pattern., (3) Assess maternal temperature.
(SELECT ALL THAT APPLY) The nurse is caring for a client who has been diagnosed with abruptio placenta. What signs and symptoms of abruptio placenta should the nurse expect to find when she is collecting data on this client?
(1) Vaginal bleeding, (3) Uterine tenderness on palpation, (6) Abnormal fetal heart tones
(SELECT ALL THAT APPLY) A client in labor is given meperidine (Demerol), 25 mg I.V., for labor pain. The nurse should monitor the client for which adverse effects of the drug?
(2) Nausea & Vomiting, (3) Respiratory Depression, (5) Tachycardia
(SELECT ALL THAT APPLY) The nurse is assisting in caring for a client who has just given birth to a neonate through vaginal delivery. The nurse is monitoring for signs of placental separation. Which of the following signs indicate that the placenta has separated?
(3) Sudden gush of vaginal blood, (4) Change in shape of the uterus, (5) Lengthening of the umbilical cord
The nurse is checking the fetal heart rate (FHR) of a client admitted to the labor and delivery area at term. Which of the following should the nurse identify as the normal range of the baseline FHR?
120 to 160 beats/minute
A client in labor is prescribed 1,000 ml of normal saline solution to infuse over 6 hours. The drip factor of the I.V. administration set is 15 drops/ml. The nurse on the previous shift hung the solution at the end of her shift. The oncoming nurse should recheck the drip rate to make sure that the I.V. is infusing at the prescribed drip rate. What is the prescribed drip rate?
42 drops/minute
An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. The nurse caring for the mother following an assisted birth should keep which of the following in mind?
A vacuum extractor is safer than forceps because it causes less trauma to the baby and the mother's perineum.
A client is recovering in the labor and delivery area after delivering a 6-lb, 3-oz boy. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings?
A vaginal laceration
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What does this finding suggest?
Abruptio placentae
Which action should the nurse perform if the client's blood pressure falls during the first or second stage of labor?
Administer oxygen through a face mask at 6 to 10 L/minute.
Which of the following physiologic changes during labor makes it necessary for the nurse to check blood pressure frequently?
Alterations in cardiovascular function affect the fetus.
Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
An increased sense of rectal pressure
Late in the first stage of labor, a client receives a spinal block to relieve discomfort. A short time later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What do the client's symptoms suggest?
Anesthesia overdose
A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate?
Applying gentle pressure to the baby's head as it's delivered
When caring for a client who's a primigravida, the nurse would expect the second stage of labor to last how long?
Approximately 2 hours
A client who's in active labor is yelling, "Get out of here!" As the nurse enters the client's room, she notices the client's estranged husband in the room. How should the nurse intervene?
Ask the husband to leave or phone security.
A client in labor develops complications and is given general anesthesia. The physician informs the husband that without emergency cesarean delivery his wife and the baby may die. The husband asks the nurse what he should do. How should the nurse respond?
Ask the husband whether he and his wife ever discussed treatment options in the event of an emergency.
A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's initial action?
Assess for presence of a full bladder.
Which care intervention is appropriate for the fourth stage of labor?
Assessing lochia and the location and consistency of the fundus
A client experiencing hard, steady labor is crying and asking for something for pain. Her medical record shows that she doesn't tolerate typically prescribed pain medications. Which nonpharmacologic intervention might be helpful to this client?
Assisting the client into another position and providing a gentle backrub
A client in the early stages of active labor wants to get out of bed and walk around the room. Which action by the nurse is best?
Assisting the client to ambulate in the room
After delivering a neonate, a client delivers the placenta. At this time, where does the nurse expect to palpate the uterine fundus?
At the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus
A client is progressing through the first stage of labor. Which finding signals the beginning of the second stage of labor?
Bearing-down reflex
A client in labor is receiving oxytocin (Pitocin). During oxytocin therapy, why must the nurse monitor the client's fluid intake and output closely?
Because oxytocin causes water intoxication
During labor, a client asks the nurse why her blood pressure must be measured so often. Which explanation should the nurse provide?
Blood pressure reflects changes in cardiovascular function, which may affect the fetus.
Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. Which of the following is the most likely cause of this situation?
Breech position
A client is admitted to the labor and delivery area. How can the nurse most effectively determine the duration of the client's contractions?
By timing the period from the onset of uterine tightening to uterine relaxation
During a busy shift on the labor and delivery unit, a nurse failed to document whether she administered a medication to aid uterine contractions. The nurse who's currently caring for the client is asked whether the medication has been successful. She explains that she hasn't been monitoring its effectiveness because she didn't know that the medication was administered. Which intervention by the nurse is best?
Call the nurse at home to inquire whether she gave the medication, then ask the client about the contractions while the physician is present.
A client is admitted to the labor and delivery area. The nurse-midwife checks for fetal descent, flexion, internal rotation, extension, external rotation, and expulsion. What do these terms describe?
Cardinal movements of labor
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
Change the client's position.
A client in the second stage of labor experiences membrane rupture. Which intervention by the nurse is appropriate?
Check for a prolapsed cord.
A client who tested positive for the human immunodeficiency virus (HIV) is in active labor. During delivery, blood splashes and contaminates the care area. Which action should the nurse take?
Contact housekeeping and ask them to clean the area because it has been contaminated by blood-borne pathogens.
A client who's in labor and who attended natural childbirth classes is asking for something for pain. What should the nurse do?
Contact the physician and support the client until something can be ordered for pain.
During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?
Contractions will be stronger and more uncomfortable and will peak more abruptly.
During assessment for admission to the labor and delivery area, a client and her husband ask the nurse whether their sons, ages 8 and 10, can witness the childbirth. Before answering this question, the nurse should consider which guideline?
Each child attending the childbirth should have a separate support person.
A client in labor tells the nurse-midwife that she feels a strong urge to push. Physical examination reveals that her cervix is not completely dilated. The nurse-midwife tells her not to push yet. What is the rationale for this instruction?
Early pushing may cause edema and impede fetal descent.
During a childbirth education class, a nurse-educator discusses pain control techniques used during labor and delivery. Which technique most effectively helps a client cope with the pain of uterine contractions?
Effleurage and other cutaneous stimulation
Which action should the nurse take to promote the descent of the fetus's presenting part?
Encourage the client to void every 2 hours.
The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Ensure adequate I.V. hydration according to the physician's order before the anesthetic is administered.
A client is in the second stage of labor. During this stage, how frequently should the nurse assess her uterine contractions?
Every 15 minutes
The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary?
Fetal heart rate of 80 beats/minute
A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?
Fetal heart rate variability within an acceptable range
Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which complaints?
Headache, blurred vision, and facial and extremity swelling
A client who comes to the emergency department in the early stages of labor is admitted to the labor and delivery unit. The nurse observes that the client hasn't recently bathed or changed her clothes. What should the nurse do to help this client?
Help the client to undress and suggest a quick bath to freshen up.
A client in labor receives epidural anesthesia. The nurse should assess carefully for which adverse reaction to the anesthetic agent?
Hypotensive crisis
A client in the early stage of labor states that she has a thick, yellow discharge from both of her breasts. Which action by the nurse is most appropriate?
Informing the client that the discharge is colostrum, which is a normal finding
A client in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn't attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be effective for the couple at this time?
Instruct the husband on touch, massage, and breathing patterns.
The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)?
Intrauterine fetal death
A pregnant client arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
Latent phase
A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Into what position should the nurse assist the client?
Left lateral
Which intervention should be included in the safety plan for the maternal-infant unit?
Making sure that the spouse or significant other wears an identification band
During the fourth stage of labor, the nurse notes that the client's fundus is boggy and located above the umbilicus. How should the nurse intervene?
Massage the client's fundus.
After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count, urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive, although the client doesn't have signs and symptoms of this disease. What is the significance of this finding?
Maternal gonorrhea may cause an eye infection in the neonate.
During labor, a primigravid client receives epidural anesthesia, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?
Maternal hypotension
During labor, a client demonstrates signs of fatigue and possible fetal distress. How should the nurse intervene?
Notify the charge nurse and prepare to assist her with necessary interventions.
For a client who's moving into the active phase of labor, the nurse should include which of the following as the priority of care?
Offer support by reviewing the short-pant form of breathing.
A client in active labor is sweating profusely and has minimal urine output. How should the nurse intervene?
Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output.
Several minutes after a vaginal delivery, the nurse observes blood gushing from the client's vagina, umbilical cord lengthening, and a globular-shaped uterus. The nurse should suspect which condition?
Placental separation
A client who's being admitted to labor and delivery has the following data collection findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time?
Preparing for immediate delivery
A 23-year-old primigravida client is in the active stage of labor. She and her husband have been using breathing techniques. The husband asks whether he can do anything more to help his wife during labor. What should the nurse suggest?
Provide helpful distractions.
When coaching a client to push, the nurse should encourage her to use which technique?
Pushing when she feels like pushing
Six clients are in active labor in the labor and delivery unit. Four additional clients in the early stages of labor were just admitted to the unit. There are three registered nurses (RNs) and two licensed practical nurses (LPNs) assigned to the unit this shift. Which client care assignment provides the best care for these clients?
RNs should be assigned to those in active labor and LPNs should be assigned to those in the early stages of labor.
During labor, a client greatly relies on her husband for support. They previously attended childbirth education classes, and now he's working with her on comfort measures. Which nursing diagnosis would be appropriate for this couple?
Readiness for enhanced family coping related to participation in pregnancy and delivery
A client admitted with preeclampsia complains of a headache. When caring for a client with preeclampsia, which action is a priority?
Reducing visual and auditory stimulation
A client in active labor believes in a holistic approach to health care. Which intervention might be useful to the client during labor?
Reiki
Relationship of the fetus's presenting part to the mother's pelvis
Relationship of the fetus's presenting part to the mother's pelvis
To obtain a good monitor tracing on a client in labor, the mother lies on her back. Suddenly, she complains of feeling light-headed and becomes diaphoretic. Which of the following should be the nurse's first action?
Reposition the client to her left side.
The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?
Shallow chest breathing
To promote comfort during labor, the nurse advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia?
Supine position
Which of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor?
Tetanic contractions
When assessing the fetal heart rate tracing, the nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if which of the following occurs?
The fetal heart rate remains at greater than 160 beats/minute for 10 minutes.
The nurse applies an external electronic fetal monitor (EFM) to assess a client's uterine contractions and evaluate the fetal heart rate (FHR). However, the client is uncomfortable and changes positions frequently, making FHR hard to assess. Consequently, the physician decides to switch to an internal EFM. Before internal monitoring can begin, which of the following actions must occur?
The membranes must rupture.
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first?
The time of membrane rupture
A 32-year-old multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. What phase of labor is she in?
Transitional phase
The nurse is caring for a client who's in the first stage of labor. What is the shortest but most difficult part of this stage?
Transitional phase
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?
Transitional phase
A client is in the third stage of labor. Which finding indicates impending placental separation?
Umbilical cord lengthening
A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which data collection finding may indicate the need for cesarean delivery?
Umbilical cord prolapse
A client has received dinoprostone (Prostin E2) to help ripen her cervix. The nurse should monitor the client for which adverse effect?
Vomiting
Which of the following should be the nurse's initial action immediately following the birth of the neonate?
Which of the following should be the nurse's initial action immediately following the birth of the neonate?
A client who has been in the latent phase of the first stage of labor enters the transition to the active phase. During the transition, the nurse expects to see which client behavior?
Withdrawal, irritability, and resistance to touch
A client, age 19, has an episiotomy to widen her birth canal. Delivery extends the incision into the anal sphincter. This complication is called:
a third-degree laceration.
When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be:
about half as long as her first labor.
The third stage of labor ends:
after the birth of the placenta.
The nurse assesses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include:
an increased pulse rate, increased respiratory rate, and decreased blood pressure.
A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the:
area between the dura mater and the ligamentum flavum.
A primigravid client is admitted to the labor and delivery area. Assessment reveals that she's in the early part of the first stage of labor. Her pain is likely to be most intense:
around the pelvic girdle.
The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal heart tones to:
assess for prolapsed cord.
During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a precipitous delivery by:
massaging and supporting the perineum.
When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to:
prevent seizures.
A client is experiencing true labor when her contraction pattern shows:
regular contractions that increase in frequency and duration.
A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for:
uterine atony.
During the fourth stage of labor, the client should be assessed carefully for:
uterine atony.
